What is the treatment approach for a child or adolescent with Avoidant/Restrictive Food Intake Disorder (ARFID)?

Treatment Approach for ARFID in Children and Adolescents

Children and adolescents with ARFID should be treated with Family-Based Treatment modified for ARFID (FBT-ARFID), which empowers caregivers to normalize eating patterns and restore nutritional status through structured behavioral interventions, supported by a multidisciplinary team including a physician, dietitian, and mental health provider. 1, 2, 3

Critical Diagnostic Distinctions

Before initiating treatment, confirm ARFID by verifying the absence of body image distortion or fear of weight gain—these features indicate anorexia nervosa, which requires entirely different treatment (eating disorder-focused CBT ± fluoxetine for bulimia nervosa, not ARFID). 1, 4, 2

Key differentiating features to document:

• No intense fear of weight gain or being fat 2
• No body image distortion 2
• No recurrent binge-purge cycles (rules out bulimia nervosa) 2
• Eating restriction driven by sensory sensitivity, lack of interest in eating, or fear of aversive consequences (choking, vomiting, GI symptoms, allergic reactions)—not weight/shape concerns 5, 6, 7

Initial Medical Assessment and Stabilization

Immediate evaluation must include:

• Vital signs: temperature, resting heart rate, blood pressure, orthostatic pulse and blood pressure 1
• Height, weight, BMI percentile or Z-score for age 1, 2
• Physical examination for malnutrition signs: purpuric lesions and gingival bleeding (scurvy/vitamin C deficiency), muscle wasting 2
• Complete blood count and comprehensive metabolic panel (electrolytes, liver enzymes, renal function) 1
• ECG if severe restriction or malnutrition present 1

Address life-threatening malnutrition first with vitamin C supplementation for scurvy and comprehensive nutritional support, but avoid parenteral nutrition except as a temporary bridge in life-threatening cases—invasive interventions risk iatrogenesis without improving function or quality of life. 4, 2

Primary Treatment: Family-Based Treatment for ARFID (FBT-ARFID)

FBT-ARFID is the evidence-based first-line psychotherapy for children and adolescents with involved caregivers, consisting of approximately 14 sessions focused on: 1, 3

• Caregiver empowerment to take charge of normalizing eating patterns and restoring weight 1
• Behavioral exposure to feared or avoided foods through graded hierarchies 5, 3
• Parental self-efficacy building—this mechanism drives treatment success 3
• Addressing the specific ARFID presentation: sensory sensitivity requires systematic desensitization; lack of interest requires appetite stimulation strategies; fear of aversive consequences requires cognitive-behavioral exposure 5, 6

Multidisciplinary Team Structure

Assemble a coordinated team with clearly defined roles: 1, 2, 8

• Physician: monitors medical stability, weight restoration goals (individualized weekly weight gain targets), manages nutritional deficiencies 1, 8
• Dietitian: conducts systematic nutrition surveys, identifies specific nutrient deficiencies (iron, zinc, vitamin B12, vitamin A, vitamin C, fiber, folate are commonly inadequate), provides meal planning tailored to sensory sensitivities 1, 2, 8
• Mental health provider: delivers FBT-ARFID, addresses co-occurring psychiatric disorders (anxiety disorders are highly prevalent in ARFID) 1, 2, 8
• Speech therapist (if indicated): addresses swallowing difficulties or oral-motor dysfunction 8

Nutritional Rehabilitation Strategy

Set individualized weekly weight gain targets and monitor growth parameters at every visit. 1

For inadequate oral intake despite FBT-ARFID:

• Oral high-energy, high-protein supplements as first step 1
• Nasogastric feeds if oral route insufficient or unsafe swallow present 1
• Gastrostomy feeds only when long-term enteral nutrition required (approximately 3% of cases) 1

Monitor for specific nutrient deficiencies given avoidance of non-soluble foods (red meat, fruits, vegetables): iron, zinc, vitamin B12, vitamin A, vitamin C, fiber, folate. 1

Medication Considerations: What NOT to Do

Do not prescribe fluoxetine for ARFID—there is no evidence supporting its use, and it is specifically indicated only for bulimia nervosa (60 mg daily for binge-purge cycles with shape/weight concerns), not ARFID's avoidant eating patterns. 4

Cognitive-behavioral therapy with graded exposure (CBT-AR) is the psychological intervention, not medication. 4

Treatment Intensity Algorithm

Outpatient FBT-ARFID is appropriate for most children ages 6-12 with involved caregivers and medical stability. 3, 7

Consider hospitalization with intensive multidisciplinary care when: 8

• Severe malnutrition with hemodynamic instability (abnormal orthostatic vitals, bradycardia) 1
• Rapid weight loss threatening medical stability 8
• Psychiatric comorbidities (anxiety, depression, OCD) severely impairing treatment participation 9
• Failure of outpatient treatment to prevent continued nutritional decline 8

Common Pitfalls to Avoid

Do not focus treatment on weight loss—the goal is normalizing eating patterns and addressing underlying psychological factors driving avoidance. 9

Do not overlook co-occurring conditions: GERD, eosinophilic esophagitis (EoE), and gastrointestinal symptoms frequently coexist with ARFID and adversely affect feeding, requiring concurrent evaluation with endoscopy and biopsy if symptomatic. 1

Do not dismiss parental and patient anxiety about meals—this psychosocial impairment is a core feature requiring direct therapeutic attention within FBT-ARFID. 1

Screen routinely for swallowing difficulties (dysphagia), particularly in patients with concerns about growth and dietary intake, as this substantially affects nutritional status and quality of life. 1